The vessel was under new owners from April1998 and, although few of the crew had previous experience with totally enclosed lifeboats, the record of lifeboat drills since the change of owners does not show that the boats had actually been in the water and manoeuvred - as required under the regulations. From the descriptions of the rate of descent of the starboard boat given by the crew, it would appear that the brake was set up for an empty boat. The starboard boat carried less than the nominal six man rescue boat crew, with a mass of 450kg, and the additional weight of crew members made the boat's descent alarmingly rapid. The speed-governing brake is adjustable and the standard adjustment should be for the maximum weight when the boat is used as a lifeboat, i.e., with the estimated 1875kg mass of a 25-person crew. The operating lever for the release mechanism of the port boat was found secured (by the safety pin) in its stowage bracket, indicating that it was not used by the boat's crew. The forward hook prematurely released at the same time as the lifeboat swung against the ship's side while it was being lowered. The violent swing could have been precipitated by the interruption in the initial lowering of the boat, which is cautioned against in the builder's instructions; but this hesitation in lowering the boat was not the intent of those attempting to lower the boat. From the position of the under-deck securing mechanism for the forward hook of the port boat, it is likely that the hook released because the cam lever was incorrectly adjusted, and the securing pawl not completely engaged, the last time the lifting hooks were reset. The after hook subsequently released when it was subjected to the full weight of the boat. The deck officers responsible for stowing the boats did not understand the sequence of operations required to reset the hooks in the boats. Also, they did not know that, before attempting to hook onto the falls, the hooks should be reset. The lack of knowledge regarding the operation of the release mechanism is confirmed by the operating quadrant of the starboard boat having been left secured in the resetting - instead of the lifting - position when the boat was recovered and returned to its stowed position in the davits. As the records indicate that the boats had not been released from the falls since the change of ownership, it is likely that the improper setting of the boat release mechanism occurred when retrieving the lifeboat during the survey in April1998. Also, the shipboard inspection of the lifeboat was less than thorough; it did not detect that the bowden cables had been incorrectly adjusted, nor did it detect the wear marks on the forward hook of the port lifeboat, wear which had taken place over a period of time. This permitted an unsafe condition to go unnoticed for at least seven months, until the occurrence. The maintenance records on board the vessel were inaccurate, in that they mentioned neither that the port lifeboat had been holed nor that the bowden cables had been incorrectly adjusted, while the entries for inspection of the hook and the release mechanism indicated that they were in good condition. The information contained in the ISM Manual is for general launching and recovery of a lifeboat, and makes no reference to the manufacturer's operating and maintenance manual. Information contained in the manufacturer's operating and maintenance manual is unclear, and may be difficult to comprehend, e.g., item7 of the launching procedure reads: To be adjusted lowering speed by remote control wire before the boat launch to the sea surface, and to be waterborned slowly. The manual also lacks information as to when the hooks should be set or how the boat is to be secured to the fall.Analysis The vessel was under new owners from April1998 and, although few of the crew had previous experience with totally enclosed lifeboats, the record of lifeboat drills since the change of owners does not show that the boats had actually been in the water and manoeuvred - as required under the regulations. From the descriptions of the rate of descent of the starboard boat given by the crew, it would appear that the brake was set up for an empty boat. The starboard boat carried less than the nominal six man rescue boat crew, with a mass of 450kg, and the additional weight of crew members made the boat's descent alarmingly rapid. The speed-governing brake is adjustable and the standard adjustment should be for the maximum weight when the boat is used as a lifeboat, i.e., with the estimated 1875kg mass of a 25-person crew. The operating lever for the release mechanism of the port boat was found secured (by the safety pin) in its stowage bracket, indicating that it was not used by the boat's crew. The forward hook prematurely released at the same time as the lifeboat swung against the ship's side while it was being lowered. The violent swing could have been precipitated by the interruption in the initial lowering of the boat, which is cautioned against in the builder's instructions; but this hesitation in lowering the boat was not the intent of those attempting to lower the boat. From the position of the under-deck securing mechanism for the forward hook of the port boat, it is likely that the hook released because the cam lever was incorrectly adjusted, and the securing pawl not completely engaged, the last time the lifting hooks were reset. The after hook subsequently released when it was subjected to the full weight of the boat. The deck officers responsible for stowing the boats did not understand the sequence of operations required to reset the hooks in the boats. Also, they did not know that, before attempting to hook onto the falls, the hooks should be reset. The lack of knowledge regarding the operation of the release mechanism is confirmed by the operating quadrant of the starboard boat having been left secured in the resetting - instead of the lifting - position when the boat was recovered and returned to its stowed position in the davits. As the records indicate that the boats had not been released from the falls since the change of ownership, it is likely that the improper setting of the boat release mechanism occurred when retrieving the lifeboat during the survey in April1998. Also, the shipboard inspection of the lifeboat was less than thorough; it did not detect that the bowden cables had been incorrectly adjusted, nor did it detect the wear marks on the forward hook of the port lifeboat, wear which had taken place over a period of time. This permitted an unsafe condition to go unnoticed for at least seven months, until the occurrence. The maintenance records on board the vessel were inaccurate, in that they mentioned neither that the port lifeboat had been holed nor that the bowden cables had been incorrectly adjusted, while the entries for inspection of the hook and the release mechanism indicated that they were in good condition. The information contained in the ISM Manual is for general launching and recovery of a lifeboat, and makes no reference to the manufacturer's operating and maintenance manual. Information contained in the manufacturer's operating and maintenance manual is unclear, and may be difficult to comprehend, e.g., item7 of the launching procedure reads: To be adjusted lowering speed by remote control wire before the boat launch to the sea surface, and to be waterborned slowly. The manual also lacks information as to when the hooks should be set or how the boat is to be secured to the fall. The speed-governing brake for the starboard lifeboat winch was improperly set, resulting in the boat's alarmingly rapid descent. In the starboard boat, which had been recovered before the attempt to lower the port boat, the quadrant safety pin had been left in the resetting position and the cams and pawls were not properly adjusted to firmly lock the hooks in the lifting position. The adjuster for the operating cable to the port boat after hook had pierced the hull below the quadrant when the cable deflected as a result of the hook being incorrectly reset. This had occurred some time earlier but had not been investigated by the crew. The crew were not aware of the correct procedure for repairing the hole in the lifeboat, nor did they follow the manufacturer's instructions. The port lifeboat forward lifting hook had not been correctly reset by a previous crew when the boat was last released from the falls. Proper adjustment of the port lifeboat release mechanism was not carried out to firmly lock the hooks in the lifting position. The manufacturer's instruction manuals on board the vessel for the lifeboat launch and retrieval operations are incomplete and difficult to comprehend. The owners ISM manual deals with general lifeboat launching and recovery practices and no reference is made to the manufacturer's operations manuals. The vessel had received an ISM Certificate some six weeks before the occurrence, and the current personnel were not familiar with the procedure to reset the lifeboats' lifting hooks. Neither the inspection by the Class surveyor nor that by the ship's crew detected the improper setting of the release mechanism, allowing the unsafe condition to go unnoticed for at least seven months. Records of the lifeboat and fire drills on the vessel indicate that the lifeboats had not been completely released from the falls since the vessel changed owners in April 1998, some seven months before the occurrence. Five out of a crew of six persons crewing the boat sustained injuries and one person lost his life.Findings The speed-governing brake for the starboard lifeboat winch was improperly set, resulting in the boat's alarmingly rapid descent. In the starboard boat, which had been recovered before the attempt to lower the port boat, the quadrant safety pin had been left in the resetting position and the cams and pawls were not properly adjusted to firmly lock the hooks in the lifting position. The adjuster for the operating cable to the port boat after hook had pierced the hull below the quadrant when the cable deflected as a result of the hook being incorrectly reset. This had occurred some time earlier but had not been investigated by the crew. The crew were not aware of the correct procedure for repairing the hole in the lifeboat, nor did they follow the manufacturer's instructions. The port lifeboat forward lifting hook had not been correctly reset by a previous crew when the boat was last released from the falls. Proper adjustment of the port lifeboat release mechanism was not carried out to firmly lock the hooks in the lifting position. The manufacturer's instruction manuals on board the vessel for the lifeboat launch and retrieval operations are incomplete and difficult to comprehend. The owners ISM manual deals with general lifeboat launching and recovery practices and no reference is made to the manufacturer's operations manuals. The vessel had received an ISM Certificate some six weeks before the occurrence, and the current personnel were not familiar with the procedure to reset the lifeboats' lifting hooks. Neither the inspection by the Class surveyor nor that by the ship's crew detected the improper setting of the release mechanism, allowing the unsafe condition to go unnoticed for at least seven months. Records of the lifeboat and fire drills on the vessel indicate that the lifeboats had not been completely released from the falls since the vessel changed owners in April 1998, some seven months before the occurrence. Five out of a crew of six persons crewing the boat sustained injuries and one person lost his life. The Board determined that while the port lifeboat was being lowered, the forward lifting hook prematurely released because the hook had not been correctly reset into the locked position the last time the boat was released from the falls. Records of the lifeboat and fire drills on the vessel indicate that the lifeboats had not been completely released from the falls since the vessel changed owners in April1998. Contributing to the occurrence was the fact that the crew were unfamiliar with the procedures for resetting hooks, the manufacturer's instruction manual for the lifeboat launching and retrieval operations was incomplete and difficult to comprehend, and the inspection by Class and shipboard personnel was less than thorough.Causes and Contributing Factors The Board determined that while the port lifeboat was being lowered, the forward lifting hook prematurely released because the hook had not been correctly reset into the locked position the last time the boat was released from the falls. Records of the lifeboat and fire drills on the vessel indicate that the lifeboats had not been completely released from the falls since the vessel changed owners in April1998. Contributing to the occurrence was the fact that the crew were unfamiliar with the procedures for resetting hooks, the manufacturer's instruction manual for the lifeboat launching and retrieval operations was incomplete and difficult to comprehend, and the inspection by Class and shipboard personnel was less than thorough. their existing designs; and their maintenance, operation and training manuals, with a view to writing procedures in simplified language or using pictorials to enhance understanding and compliance, especially where the language of communication of the ship's crew may not be English. their existing designs; and their maintenance, operation and training manuals, with a view to writing procedures in simplified language or using pictorials to enhance understanding and compliance, especially where the language of communication of the ship's crew may not be English. Transport Canada has prepared a paper which is being processed for submission as an agenda item at the 44th Session of the Sub-Committee on Ship Design and Equipment of the IMO. The submission notes the actions recommended in item No3, above, and suggests that other administrations may wish to follow these actions. Under the Port State Control Inspection Program, Marine Safety inspectors are being instructed to ensure that special attention is given to this aspect of life-saving equipment and that if a deficiency is detected it must be dealt with, or the vessel detained. Discussions are ongoing between Marine Safety headquarters and representatives of all regional offices, regarding SOLAS 1974 Chapter3, Regulation18, Section3.6 (the frequency of abandon-ship drills). The operation and maintenance of free fall lifeboats, including the mandatory securing of such boats with a restraining strop, is also being discussed.Safety Action Taken their existing designs; and their maintenance, operation and training manuals, with a view to writing procedures in simplified language or using pictorials to enhance understanding and compliance, especially where the language of communication of the ship's crew may not be English. their existing designs; and their maintenance, operation and training manuals, with a view to writing procedures in simplified language or using pictorials to enhance understanding and compliance, especially where the language of communication of the ship's crew may not be English. Transport Canada has prepared a paper which is being processed for submission as an agenda item at the 44th Session of the Sub-Committee on Ship Design and Equipment of the IMO. The submission notes the actions recommended in item No3, above, and suggests that other administrations may wish to follow these actions. Under the Port State Control Inspection Program, Marine Safety inspectors are being instructed to ensure that special attention is given to this aspect of life-saving equipment and that if a deficiency is detected it must be dealt with, or the vessel detained. Discussions are ongoing between Marine Safety headquarters and representatives of all regional offices, regarding SOLAS 1974 Chapter3, Regulation18, Section3.6 (the frequency of abandon-ship drills). The operation and maintenance of free fall lifeboats, including the mandatory securing of such boats with a restraining strop, is also being discussed.